Student Enrollment

Student Information

Legal First Name*

Answer Required

Legal Middle Name

Answer Required

Legal Last Name*

Answer Required

Preferred Name

Answer Required

Grade Entering*

Answer Required

Date of Birth*

Answer Required

First language spoken by student*

Answer Required

Languages spoken at home*

Answer Required

Health Insurance Provider*

Answer Required

Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Home Phone

Number Required

Parent 1 Information

First Name*

Answer Required

Middle Name

Answer Required

Last Name*

Answer Required

Email*

Answer Required

Mobile Phone*

Number Required

Work Phone

Number Required

Parent 2 Information

First Name

Answer Required

Middle Name

Answer Required

Last Name

Answer Required

Mobile Phone

Number Required

Work Phone

Number Required

Emergency Contact Information

First Name

Answer Required

Middle Name

Answer Required

Last Name

Answer Required

Relationship to Student

Answer Required

Phone Number

Number Required

Family Doctor Information

Name

Answer Required

Phone

Number Required

Student Transportation Information*

Answer Required

My child walks or rides their bike to/and from school

My child will ride this bus to and from school

My child will be dropped/picked up by authorized persons

Who are said authorized persons? (If applicable)

Answer Required

Student Medical Information

To the best of my knowledge my child is healthy and fit to participate in related activities:*

Answer Required

Yes

If no, please explain

Answer Required

My child currently experiences or has recently had a diagnosis for (please check all that apply)

Answer Required

ADD/ADHD

Allergies

Asthma/Inhaler

Diabetes

Other:

If other, please explain

Answer Required

My child is currently taking medication(s)*

Answer Required

Yes

If yes, please explain the medications

Answer Required

Child's Proof of Age

A birth certificate, passport, or other approved documentation

Answer Required

Choose a file or drag it here.

Child's Immunization Records

All immunizations must be up to date before your child(ren) may enter the classroom

Answer Required

Choose a file or drag it here.

Robla New Hope Charter School

Please fix the highlighted areas below before submitting.

Student Enrollment